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Creating Structure for Sharing Information and Knowledge in Ambulatory Care: Two Exemplars

Posted By Administration, Thursday, May 11, 2017
Updated: Thursday, May 11, 2017

Breakout sessions at the upcoming NPSF Patient Safety Congress discuss how critical information sharing is to safety improvement work.

by Lorri Zipperer, MA


Communication between individuals to leverage what is known in all types of care environments can be difficult. Whether at the organizational or team level, defined goals, processes and expectations help to shore up what information is shared, how it is delivered, and what is done with it.


Two sessions at the 2017 NPSF Patient Safety Congress in Orlando will provide insights into effective information sharing in ambulatory care. They target two important initiatives that benefited from defined methods of information sharing—organizational learning from adverse events or near misses and patient transitions from the hospital to primary care teams. The speakers will discuss their experiences to highlight value associated with taking the time to build processes to apply information and knowledge in support safe care.


Improvement through sharing lessons learned

PeaceHealth recognized that the work done to improve processes wasn’t reliably assimilated to help their organization learn. “We have learned that robust event investigation requires a system-level structure to triage outpatient safety events,” said Andrea Halliday, MD, patient safety officer, PeaceHealth.“Otherwise, problems are solved on a clinic level and we miss an important opportunity to learn from our events and to spread the lessons learned.”


To help their outpatient clinics design and implement improvement strategies drawn from system-reported adverse events and near misses, PeaceHealth:  

  • Established a leadership team to track and discuss events
  • Launched and supported communication opportunities over time
  • Encouraged accountability through documented improvement action plans
  • Monitored the initiative to track its impact

This structured approach didn’t leave learning to chance. It didn’t assume that sharing was happening. Instead the organization committed to a process that raised awareness of the importance of learning from what goes wrong.

"We have learned that robust event investigation

requires a system-level structure

to triage outpatient safety events.".

—Andrea Halliday, MD


Session 305 will discuss the methods used to enable improvements across the ambulatory care continuum of a large health care system.


Safe patient transition from hospital to the community

Transitions are ripe for communication gaps, missteps, and misunderstandings. Transitions from one environment to another offer extra challenges as the team who knows the patient best can be disconnected from their care due to the changed location. Adding to the complexity, the patients may not always be effectively engaged in the process to confirm that they have the information they need to ensure their safety once outside the hospital (See Horwitz et al. 2013)


Handoff tactics such as standardized information bundles and checklists have been noted to make information sharing more reliable in the hospital and after discharge. Breakout session 505 builds on those successes to highlight an improvement strategy at Iora Health for use as patients enter the primary care management space: transition navigators.


“Our experience has shown that involvement of primary care teams when patients are hospitalized is invaluable,” said Sumair Akhtar, MD, MS, associate medical director, culinary extra clinic, Iora Health. "We understand that in a busy practice, it is nearly impossible for most PCPs to directly engage with inpatient teams on every occasion, therefore, to improve the primary care team's influence and involvement in inpatient care, we have proposed a multidisciplinary model that leverages team nurses and clinically savvy non-clinicians (with solid process and simple tools) to be the liaisons between the patients, caregivers, and inpatient and primary care teams.”


The speakers will discuss how transition navigators help to ensure that communication is clear and concerns are addressed when patients transfer out of the acute care environment. They will share tools and measures that have supported the development of this innovative member of the care team. 


Both these sessions will discuss ways to ensure that information and knowledge sharing wasn’t left to chance. They support the value of resourcing and tending to processes of transferring information to ensure that organizations and care teams are prepared to safely serve patients and families.


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Patient Safety Beyond the Walls of the Hospital is one of six Breakout Tracks featured at the NPSF Congress May 17-19. View more details.

What methods do you employ at your organization to support effective information? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.


Lorri Zipperer, MA, is the principal at Zipperer Project Management in Albuquerque, NM, specializing in knowledge management efforts and bringing multidisciplinary teams together to envision, design, and implement knowledge sharing initiatives. Among her publications, Ms. Zipperer recently served as editor for two texts, Knowledge Management in Healthcare and Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer, both published in 2014, and as a co-editor for the 2016 publication Inside Looking Up, published by The Risk Authority Stanford.

Tags:  2017 Patient Safety Congress  communication  transitions 

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Leadership, Culture, and Patient Experience Take Center Stage

Posted By Administration, Thursday, September 24, 2015
Updated: Thursday, September 24, 2015


     Afternoon keynote speaker Dr. Skip Campbell
A video tribute to Dr. Lucian Leape
kicked off the evening program.

    Dr. Sands (left) with panel participants (from left): Dr. Richard Whyte;
Dr. Pat Folcarelli; Mary Fay, RN; Jeff Catalano, Esq.;
and Nancy Watson, JD.


The 8th Annual NPSF Lucian Leape Institute Forum & Keynote Dinner touched upon issues that are the keys to moving the patient safety agenda forward.

by Patricia McTiernan, MS


Would your hospital allow a news reporter to follow along as the leadership team conducted WalkRounds? What does your hospital do to provide support to clinicians involved in medical errors? Would you ever hesitate to recommend your physician or hospital to a friend or loved one?


These questions may not come up in day-to-day patient safety work, with its focus on numbers, data, protocols, and checklists. But they are among the thoughts provoked by the presentations at this year’s NPSF Lucian Leape Institute Forum & Keynote Dinner, held in Boston last week. Leadership, culture, patient experience, and workforce safety took center stage as the event’s presentations demonstrated the value of transparency in health care and the importance of leaders in influencing behavior within our health care organizations.


The Institute’s most recent report argues that greater transparency in health care – at all levels – can fuel better, safer care. With that report as the backdrop, Dr. Darrell “Skip” Campbell shared experiences from his work as a surgeon, researcher, and chief medical officer as well as from his current role as director of the Michigan Surgical Quality Collaborative.


Dr. Campbell pointed to research that showed that staff who had participated in Leadership WalkRounds were more likely than those who had never participated to say they would speak up when faced with a potential or actual medical error. During his time at University of Michigan Health System, Dr. Campbell was so confident in the promise of WalkRounds to drive improvement, he invited a news reporter to observe the ritual.


In his role as director of MSQC, Dr. Campbell works on a different level of transparency—between providers. MSQC is certified by the Agency for Healthcare Research and Quality as a patient safety organization and is made up of 73 member organizations across the state that agree to share data on surgical outcomes and not compete on safety.


MSQC works to identify top performers through the analysis of data; visits them, talk to them, and figures out what it is that they are doing to achieve the good results; and then distributes that information to the other members. One of their early successes has been a state-wide decrease in surgical site infections after colectomy.


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Breakout Knowledge

Dr. Gary Kaplan, chairman and CEO of Virginia Mason Health System and chair of the NPSF Lucian Leape Institute noted in his opening remarks that there are challenges and opportunities around the issue of transparency, as well as significant barriers. The Institute’s current focus is on translating its recommendations into action.


In breakout sessions, forum attendees discussed these issues. Rick Boothman, JD, chief risk officer at University of Michigan Health System and a member of the NPSF Board of Directors summarized the key points of consensus from the groups:

  • The single biggest area of concern is leadership’s role and the widespread failure to set expectations to create and support a safety culture.
  • Education is valuable, but it needs to be done correctly and embedded in the organization’s behavior.
  • Transparency can be powerful tool, but it needs to be used responsibly, with data that make sense and are delivered in useful ways.
  • There is a lack of appreciation for engagement by boards of directors in the issue of patient safety; board education on the issue is needed.
  • Provider-to-provider sharing of data and information is difficult to achieve, but is essential for progress.
  • Everyone in the organization needs to support the core mission of patient and workforce centricity – whether they are a housekeeper or a lawyer.
  • Information without action is not productive. It is the responsibility of the person reporting substandard care to be accurate, fair, and thorough, and the responsibility of the receiver to listen and understand the problem with the goal of fixing it if possible.

Where Does Apology Come In?

The afternoon concluded with an overview of the Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI) and a panel discussion featuring staff of Beth Israel Deaconess Hospital in Boston, an organization that helped pioneer the MACRMI roadmap to respond to adverse events and suspected medical errors.


Dr. Alan Woodward was instrumental in starting MACRMI in 2005, when he was president of the Massachusetts Medical Society. “We were beating our heads against the wall with tort reform,” he said. “But we wanted to do something about patient safety.” He met with Rick Boothman at the University of Michigan, and eventually formed an alliance of hospitals in Massachusetts. Dr. Kenneth Sands, chief quality officer of Beth Israel Deaconess, served as principal investigator of MACRMI’s study, funded by the Agency for Healthcare Research and Quality, to identify the major impediments to apology and disclosure and strategies to overcome them. This work led to the MACRMI roadmap, known as CARe—communication, apology, and resolution following medical injury.


Dr. Woodward described CARe as a proactive process to review the case, advocate for the patient’s medical needsand if the injury was found to be avoidable, their financial needs—and to render appropriate apology, which he said, "is therapeutic for both clinicians and patients.”


Dr. Sands facilitated a panel discussion of a case that was handled through the CARe process. In the case presented, a communication breakdown led to a delayed cancer diagnosis. Speaking via a video, the patient explained that she found out she had cancer only after persisting in telling her doctor that something wasn’t right after her gallbladder surgery. “Patients shouldn’t have to figure this out for themselves,” she said.


In an important part of the process, the patient met with the vice chair of the department of surgery, who explained what happened and how, and what the organization was doing to prevent it from happening again.


Pat Folcarelli, RN, PhD, director of patient safety at BI Deaconess said that “physicians usually leave such a meeting feeling very positive. We prepare them beforehand, [telling them] that it is a critical meeting to communicate openly about what happened. Despite anxiety, most leave thinking they’ve been given a gift in terms of interaction with the patient and family that they hadn’t had before.”


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Making It Personal

Dr. Jonathan Perlin, the evening keynote speaker, began his talk, "To Care Is Human," by asking the question, “Would you ever hesitate to recommend your physician or hospital to a friend or loved one?” A former, long-time member of the NPSF Board of Directors, current chair of the American Hospital Association, and chief medical officer of Hospital Corporation of America, Dr. Perlin argued that patient safety and patient experience go hand-in-hand. He told four patient stories, each through the lens of the HCAHPS survey (Hospital Consumer Assessment of Healthcare Provider and Systems).


Would you ever hesitate
to recommend your physician or
hospital to a friend or loved one?

Two of the cases involved breaches of hand hygiene. In one case, the patient, a retired nurse, did not speak up to the anesthesiologist because she knew “for the next four hours, my life would be in his hands.” In another case, speaking up to a clinician about hand hygiene led to a rebuke about how “disruptive visitors can be asked to leave.”


Apart from noting that the most common mode of transmission of pathogens is via the hands, and that there are roughly 80,000 hospital acquired infections each year, Dr. Perlin also fixed on the patient’s perceptions: how would those patients respond to HCAHPS survey questions such as “Would you recommend this hospital?” and “How would you rate the nurses’ response to concerns or complaints?”


A noted expert in health information technology, Dr. Perlin suggested that better use of data could also help providers improve care and safety. “If each of us read two articles per night, we’d only be behind by 10,000 articles,” he said. “Care informs care.” More effective use of the digital records we are creating can be part of a learning health system.


Making it personal, Dr. Perlin concluded by saying that each patient he had discussed was a member of his own family. “Patient experience isn’t just about being nice,” he said. “Patient safety is inextricably linked to patient experience. It involves culture and leadership, with the patient at the center.”

Have you done work to improve the culture or the patient experience in your organization? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

About the Author: Patricia McTiernan, MS is assistant vice president for communications at the National Patient Safety Foundation and editor of the P.S. Blog. Contact her at

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Tags:  apology  Boothman  Campbell  communication  culture  Gandhi  Kaplan  leadership  Leape  Sands  transparency 

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Breaking Health Care’s First Commandment

Posted By Administration, Friday, June 26, 2015
Updated: Friday, June 26, 2015

Creating communications bridges between departments is vital to avoiding breakdowns in infection protocol.

by Nanne Finis, RN, MS


The often-quoted phrase “First, Do No Harm” is not really in the modern Hippocratic Oath. But a recent study of medical errors in U.S. hospitals suggests that perhaps it should be widely adopted as the first commandment of health care.


That study estimates the true number of deaths due to preventable errors may be four times more than the 98,000 per year quoted by the Institute of Medicine in its report To Err Is Human.


A culture of safety?

Given the mission of health care institutions, the general public might be surprised to hear the rising chorus of health professionals calling for a “culture of safety” to be adopted in our nation’s hospitals. Yet a 2012 IOM study reported that one-third of all hospital patients experience some form of hospital acquired conditions (HACs), ranging from minor injuries to death.


Infection, for example, was historically considered an acceptable risk of providing care, but recent changes in reimbursement regulations mandated reductions in medical errors and penalized re-admissions and infection-related length of stay. Now a whole range of technologies is available to contain the spread of infection, from robots that blast germ-killing ultraviolet light to remote monitors that keep track of hand hygiene compliance by health care workers.


But problems persist. The Joint Commission, which accredits more than 75% of U.S. hospitals, found infection prevention and control deficiencies in about half of the hospitals it surveyed in the first half of 2014. Although one in 25 hospital patients will acquire an infection during treatment, more than a third of U.S. hospitals that responded to a recent survey reported they do not have a certified infection prevention specialist on staff.


While progress is being made, it’s clear that more needs to be done. Although handwashing is regularly touted as the best way to fight infection, handwashing studies of hospital staff repeatedly place compliance in the 30% to 40% range. Health care providers need more tools to protect workers and the general population.


Readmissions and communication breakdowns are other areas of concern. A record 2,610 hospitals are under CMS penalties for readmissions. Last year, nearly 18% of Medicare patients were readmitted within 30 days. That’s two million patients at a cost of $17 billion.


The Ebola scare in a Dallas hospital last fall raised a number of new questions about communications breakdowns, preparedness, and the priority given to patient safety in U.S. hospitals. Two nurses infected with Ebola while treating a Liberian national were successfully treated for the disease, but the outcome could have been far worse. The death of “Patient Zero” in Dallas could have happened at almost any hospital in the world. And it could happen again, as long as the potential for breakdowns in communication exists.


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The Infection Multiplier Effect

A hospital that my organization worked with reported to us that one infected hospital patient was found to have come in contact with 216 people in a single day. This was during the course of a normal day of treatment. Even if a small percentage of that group was infected, imagine how quickly things could spiral out of control, especially with a virulent strain of infection.


With that kind of potential for exposure, it’s vital that hospitals have the means to identify within minutes all of the hospital personnel who may have come in contact with a contagious patient. The same goes for medical devices and transport equipment.


Creating communications bridges between departments is vital to avoiding breakdowns in infection protocol. Most hospitals still use manual processes to distribute warnings about infected patients, including physically posting isolation status at the entrance to patient rooms. This can lead to inadvertent infection exposure among hospital employees who enter the room before the warning has been posted.

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Leaders must lead

Saying that “safety comes first” isn’t enough. What drives continuous success are accountability, transparency, and regular communication. While it is laboriously time-consuming to monitor protocols and track infectious patients, health care IT is bringing real-time operational visibility to patient safety and care delivery.

  1. Check to see how well your departments talk to each other. Manual processes, like posting isolation status at the entrance to patient rooms, are too slow for the pace of today’s hospital environment. This outdated process could lead to inadvertently infected hospital employees because they haven’t been alerted to the presence of infection in a patient or patient room.

  2. Make sure there is a single source for infection information so employees don’t have to seek out details in patient records. Make someone in the organization the point person for mobilizing key stakeholders from nursing, emergency medical services, emergency medicine, critical care, infection prevention and control, and give that person the responsibility of working with external government health departments and emergency management.

  3. If your infection control processes have been in place for years and if infection rates have been trending up, find out whether hospital leadership has explored the benefits of implementing infection-tracking technology.

  4. Finally, find out if technologies currently in place have been optimized to support infection prevention. Some systems come with embedded features that only need to be activated. Among these are Real Time Location Systems (RTLS), patient flow systems, and capacity management platforms

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What’s available now?

Current technologies can also chart the path of anyone or anything (like medical devices) that came in contact with an infected patient. Some allow infection warnings to stay with the patient as long as the condition lasts and wherever the patient travels within the hospital, providing a second line of defense against the spread of infection. Isolation status can be instantly distributed to care team members, environmental services staff and transport employees via page, mobile and desktop computer alerts. Hand washing monitoring systems can provide real-time reports on compliance, including name, time, and location enterprise-wide.


Prepare, prepare, prepare

"If an Ebola patient walks into a hospital that has a high rate of infection,” says Leah Binder, president and CEO of The Leapfrog Group, “they are going to be woefully unprepared.”


Technology is no silver bullet. Without discipline, infection control is problematic no matter what plans are in place. Getting serious about safety is the first of many steps that will need to be taken to ensure the safety of patients, hospital employees, and the public at large, given the current state of infection control.


Does your organization do an effective job of communicating about infection control and risk? Comment on this post below. (To comment, please log in. If you are not already registered on our site, please register here.)

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Nanne Finis, RN, MS, is vice president of consulting services at TeleTracking Technologies, Inc. Contact her at

Tags:  communication  infection  readmissions 

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